Don't get complacent

It's important that everyone realizes that the Senate isn't necessarily going to save the ACA. The worst outcome is a very real possibility:After the House passed its health care bill last week, Senators looked apt to take that dramatically conservative plan, stick it in a filing cabinet, and start over with a more moderate bill ― one that may never be able to pass the House on the way back.

But Democrats may overestimate the level of disagreement between the two chambers. And if the last two months have proved anything, it’s that we’re underestimating the ability of Republicans to accept a flawed bill in the name of winning.

We may also be surprised by what House conservatives could accept from the Senate.

House Freedom Caucus Chairman Mark Meadows (R-N.C.) has already been working with Senate Republicans on what changes House conservatives could live with, knowing that the Senate bill will probably undo some cuts to Medicaid and perhaps a key amendment that brought conservatives onboard in the first place.

“If it’s moving to the left, we just need to make sure we’re not losing too many conservative votes,” Meadows told HuffPost on Friday. “Obviously it’s going to get more relaxed as it relates to the Medicaid expansion.”

One massive change that House conservatives could accept, perhaps even welcome, is to ditch a dominant feature of the House replacement: the advance refundable tax credits.

Instead, conservatives may just take some changes to the Obamacare subsidies.

“The fundamental question is going to come down to the tax credit subsidy in place, or do they drop back to an Obamacare modified subsidy,” Meadows said.

All along, conservatives have insisted that the tax credits might be another entitlement program. But they were willing to accept that feature of the replacement because it could save money and was one of House Speaker Paul Ryan’s favorite health reform ideas. There was also a rider associated with the tax credits that prohibited those funds from going to purchase insurance plans that cover abortion.

That abortion provision looks apt to be removed in the Senate as a consequence of Republicans using a reconciliation bill. (The so-called Byrd rule subjects provisions without a real budgetary impact to a 60-vote threshold.) That could be a real problem for Republicans. A number of conservatives have told HuffPost they don’t see how a bill without a Hyde amendment rider ― which prohibits taxpayer funds from going toward abortions ― could get through the House.

Certainly, if conservatives want to hold the line on that issue, and if moderates remain opposed to what comes back from the Senate, there is a real chance Obamacare could be saved by conservatives who are unwilling to bend on abortion.

“It was made such a predicate,” Meadows said of the abortion rider and Republicans supporting the tax credits. “It’s not just the Freedom Caucus.”

The Senate looks like it will write a bill using the tax credits, potentially offering more assistance for seniors who could see their premiums skyrocket under the House bill, and potentially scaling back some of the tax credits for younger people.

“I’ve had discussions with Sen. [John] Thune [R-S.D.] on an idea to address tax credits for those in their 50s and 60s and the working poor, and he’s had some very thoughtful, meaningful ideas on how to address that that would certainly be accepted by conservatives, if that’s the direction the Senate decides to go,” Meadows said.
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Suffice it to say, on those wonkier but still significant points, the Senate has some leeway to make major changes. But if conservatives are going to draw a line on abortion, that could be a real problem ― the question is whether they would really derail a repeal and replacement of Obamacare over that issue.